As medical director of the Child and Adolescent Behavioral Health Facility in Willmar, Realmuto, M.D., a practicing psychiatrist and professor emeritus in the University of Minnesota Medical School’s Department of Psychiatry, worked closely with these young people who’d been sent to his hospital for treatment, prescribing antipsychotic drugs and a range of therapeutic interventions to help them find stability during their multiple-week hospital stays.
“Four or five years ago, when the quality of marijuana became much more potent, we started seeing these cases,” Realmuto explained. In the past, he said, this would happen rarely: “You’d occasionally see somebody who had a genetic variant or used marijuana laced with bath salts or come other chemical that affected the brain and caused psychosis, but this was happening much more often. The key thing we could identify in these cases was that prior to their psychotic episode, these young people were using a lot of cannabis. They were using it every day.”
Realmuto, who retired from his position at the Willmar hospital in June 2019, recalled that his patients’ symptoms were interfering with their ability to function in everyday life.
“Their thinking was not linear,” he said. “They were bringing fictitious ideas into an everyday problem like, ‘Let’s do some math homework.’ Their response was, ‘I can’t do math homework because the numbers fill up my brain and then it will explode.’ A kid whose brain is working like that is not going to do well in school.”
Realmuto chalked up these psychotic responses in young people to their ingestion of marijuana containing elevated levels of THC, the psychoactive compound in cannabis, achieved with the help of genetic engineering and cultivation.
“The potency of THC in cannabis makes a difference,” he said. In past decades, he continued, “what we called ‘Woodstock weed’ had a potency of between 1-3 percent. Through modern agricultural developments, the potency of marijuana can now reach 20 percent.”
High levels of THC, Realmuto said, can have a negative impact on the developing brain. With the real potential for legalization of recreational cannabis on the horizon in Minnesota, he’s become a vocal advocate for pushing the state’s legal age for cannabis purchase and use from the proposed 21 to 25, an age when he and many of his neurodevelopmentalist colleagues agree that human brain is more fully developed, lessening the risk of adverse reactions from the use of cannabis with high THC levels.
State Rep. Ryan Winkler, DFL-Golden Valley, is the House majority leader and chief author of Minnesota’s bill to legalize cannabis, which passed in the House on Thursday but faces strong opposition in the Republican-controlled Senate. Winkler doesn’t think raising the legal age for recreational cannabis to 25 is justified from an ethical or a legal perspective.
“Cannabis, alcohol and tobacco all are products that exist in our state and are widely used,” he said. “Cannabis is less risky than alcohol and tobacco for our health. To set a higher age standard for cannabis than we do for alcohol and tobacco doesn’t make any sense from a health perspective.”
Marijuana is already readily available to many young people in Minnesota, Winkler said. The legalization of recreational cannabis would help regulate its distribution and make buyers aware of the potency levels of the products they were buying, potentially reducing the use of more dangerous high-THC strains.
“Two-thirds of teens say they can get pot very easily or at least as easily as they can get alcohol,” Winkler said. “Making it illegal and trying to use the police to stop its distribution doesn’t work.”
Realmuto said that there is a clear divide between pro-legalization legislators like Winkler and mental health professionals who have seen firsthand the negative impact of the drug on younger patients.
“This is where the author of the adult cannabis bill and the scientists part ways,” he said. “There is not a prevention plan or an educational plan that tells teens, ‘This is harmful,’ the way there are prevention and education programs in the state for alcohol and opioids. Without that, teens believe that because it is called ‘recreational’ marijuana, it would be OK or safe for them.”
To advocates who say that cannabis is less harmful than alcohol or tobacco, Realmuto said, “For adults, that may be true, but unfortunately for those with developing brains — a brain develops until it is 25 — there are real harms.”
Sara Polley M.D., a child, adolescent and adult psychiatrist at Prairie Care, a Minnesota-based provider of inpatient and outpatient mental health care for children, adolescents and adults, said that she has seen the real impact of the heavy use of high-potency cannabis among her patients.
“At any given time, I’d say we’ve got at least one to two kids in our inpatient unit that are psychotic secondary to using marijuana or a substance that they didn’t know was mixed with it,” Polley said. “The marijuana that is available now is much more potent than marijuana that was smoked in the past. Every year it gets more potent.”
She said that though she supports the legalization of recreational cannabis in Minnesota, her experience with young patients has led her to agree that the legal age for purchase should be raised.
“Because the brain is still not finished developing in someone under the age of 25 or 26, they are more sensitive to being impacted or disrupted than someone whose brain has fully developed. I’m in the camp of supporting the later age — age 25.”
Joshua Stein, M.D., Polley’s colleague at Prairie Care and president of Minnesota Society of Child and Adolescent Psychiatry, said that when making the argument for upping the legal age for cannabis purchase, he likes to compare the developing brain to a growing shrub.
“The underdeveloped brain is more complicated than the 30-year-old brain,” Stein said. “A 30-year-old brain is a very well manicured hedge. It has already gone through extensive pruning. A young brain is full of twigs and sticks. It is an unpruned brain and therefore it is at very high risk.”
He supports the idea that the legal age for purchase of cannabis in Minnesota should be higher than the proposed 21. “I think that from a medical perspective, 25 makes the most sense,” Stein said. “That should be the goal if we are going to legalize.”
A different definition of adulthood?
Setting the legal age for the purchase of recreational cannabis at 25 would require Minnesotans to redefine their definition of what it means to be an adult, said Zachary Robins, a Minneapolis-based attorney who has worked with a number of companies in the state’s cannabis industry.
Minnesotans age 21, Robins said, “are an age group that can legally purchase cigarettes and alcohol and go to war. We’d be telling them, ‘You need to be 25 — the same age that you need to be to reserve a rental car — to purchase recreational cannabis’? I don t think that’s practical whatsoever.”
Even though the sale of recreational cannabis is illegal, young people in Minnesota already have ready access to the drug, Robins said. Enforcing existing laws that criminalize the sale of marijuana is costly, and the racial profiling that too often happens around drug laws perpetuates an unjust system. Decriminalizing the sale of marijuana will reduce law enforcement costs, Robins added — extending the age for the legal purchase of recreational cannabis will require beefed-up policing efforts among a population that already disproportionately suffers at the hand of law enforcement.
“I don’t think it is wise to spend federal, state and local dollars to police the sale of this product between the ages of 21 and 25,” he said.
Realmuto said that the argument that alcohol is legal at age 21 so therefore marijuana should also be legal at 21 is “frivolous.”
“The way the brain develops, there are nerve tracks, especially in adolescents, where there are a lot of changes in the brain. If you influence a developing brain with THC, it will develop differently. In some cases, there will be psychosis.”
Nationwide, the recreational cannabis legalization train is already out of the station, Winkler said. Teens generally consider marijuana to be a safer alternative to alcohol, tobacco or other drugs. If the legal age for recreational cannabis were set at 25, young Minnesotans would continue to purchase the drug from illegal sources, steal from their parents’ stash — or drive to a neighboring state. “Making pot illegal and trying to use the police to stop its distribution just doesn’t work,” Winkler said. In U.S. states that have so far legalized recreational cannabis, the legal age for purchasing is, across the board, 21.
Winkler added that taking a criminal justice-focused approach to recreational marijuana has “completely failed to keep cannabis out of the hands of those young people that they are concerned about. The question is, ‘How do we make sure that kids get the right education about this drug and how do we have control over the cannabis that exists in our community?’” Revenue tied to the legal sale of recreational cannabis will help provide those resources, he believes.
Simply accepting the fact that young Minnesotans already have easy access to marijuana as a reason to set the legal age for its recreational sale at age 21 feels like accepting the status quo without knowing all the risks, Stein said. “More kids use marijuana than use alcohol. We know that. It is standard across high schools. Most kids think it is natural and do not think it is a risk for them.”
Acceptance of this reality ignores the fact that heavy use of cannabis with high THC levels can, Stein said, “really cause psychotic issues in children and adolescents, especially those that may be already prone to schizophrenia. What we are seeing in the hospital is a group of children who smoked marijuana and became psychotic after regular use.”
The unifying element in the cases of psychosis in patents under age 25 is sustained, heavy use of cannabis, Polley added.
“We know that when it comes to brain development, that the frontal lobe, the part of your brain that helps with impulse control and decision making, is still under construction into the mid-20s,” she said. “Research has shown that regular marijuana use impacts the development of that part of the brain and can create life-long deficits for individuals who use marijuana three times a week or more.”
The existing recreational drugs with legal status in Minnesota have the potential to be more harmful to a developing body and brain than cannabis, said Jacob Mirman, M.D., medical director and cofounder of Life Medical, a full-service primary care clinic based in St. Louis Park.
“Legally available drugs such as alcohol and tobacco are obviously infinitely more damaging to the body than cannabis,” Mirman said. If used inappropriately, he added, other legally prescribed drugs, such as “amphetamines, benzos, antidepressants are all much more damaging than cannabis.”
Mirman certifies patients with qualifying conditions for medical marijuana, but he said he actually isn’t a proponent of the recreational use of any substance. “I think it isn’t a good idea to recreationally use any drug at any age,” he said. “The younger you are, the worse it is.”
Polley, Realmuto and Stein all accept that the legalization of recreational cannabis is inevitable in Minnesota. They just don’t want their concerns about the dangers of excessive use for the developing brain to get pushed aside.
“As we take these steps toward recreational legalization we should have an awareness of the dramatic risk to the young brain,” Stein said. “We need to consider that as we take steps forward and be thoughtful.”
Handle with care
Robins explains that his advocacy for the legalization of recreational marijuana does not make him an advocate for its overuse. He said that recreational legalization will eventually reduce the drug’s illicit, forbidden feel: When an adult can purchase cannabis at store just as they can purchase a six-pack of beer, people will use it more responsibly.
That’s largely been the experience in states with longer histories of recreational legalization, he said. “There are certain social norms that we all just understand with alcohol that we take for granted, like, ‘You do not show up for work intoxicated.’ It is also a social norm that you should not show up to work stoned.”
Polley supports her colleagues in the assertion that 25 is a safer age for recreational cannabis, but she said that she sometimes takes a more relaxed approach when working with her young patients. Avoiding cannabis altogether is the safest route for young people, she believes, but there have been times when she’s struck a bargain.
“I’m probably more on the liberal end compared to most of my physician colleagues,” Polley said. For her, it’s all about moderation: “There are some patients where my perspective is, ‘If you are smoking every week but are still functioning and still alive, I am OK with that.’”
She said that her qualified support for recreational legalization is based in part on her medical experience and in part on her awareness of the very real inequities faced by some racial and ethnic groups.
“If you are a Black kid walking down the street with marijuana, you might have a much different experience with the police than if you are a white kid walking down that same street with marijuana,” Polley said. “To talk about these issues from a medical perspective isn’t really relative because it occurs in the social context.” This means that, she explained, opposition to significant social change like legalization has to be handled with care.
“You can’t make these decisions while ignoring the social issues involved,” she said.
Stein said that Polley’s perspective on legalization reflects what he sees as a “dichotomy” in the world of psychiatry: “Commonly, the older population of psychiatrists do not want cannabis to be legalized. The younger population expect it to be legalized but we want to make sure that there is awareness and money that comes with it.”
Realmuto, for his part, said he doesn’t just see the bad side of cannabis.
“There are some ways that people are helped by marijuana,” he said. “There is this ridiculous fight between the people who find it useful and people like me who say there are harms associated with it, especially for minors. If adults have their own reason for relaxing at night with recreational marijuana, I have no issue with that. It is a different population I’m concerned about, and I’m not going to keep quiet about that.”